Canada is pouring billions into team-based primary care. Ontario has committed $1.8 billion to build interprofessional primary care teams. The federal Team Primary Care initiative brought more than 20 health professions together to collaboratively develop primary care curricula for the first time. But as I argued in these pages last year, we are building teams without the needed infrastructure. The training gap is real. The governance gap may be worse.
The gap starts within each profession. Regulatory frameworks were designed for individual practitioners, not for professionals working as members of primary care teams. Each profession regulates its own members. None has governance designed for how those members should function in a team delivering comprehensive, continuous, coordinated care.
The harder question lies between professions. In a Health Home or family health team, clinical care is provided by different health-care professionals, many seeing the same patient in support of the delivery of comprehensive, continuing, coordinated care. When a pharmacist adjusts a medication plan that affects a physiotherapist’s rehabilitation plan and the family physician is in the midst of making a new clinical diagnosis, how are decisions that are made within each profession’s scope managed if they are not aligned? Who is responsible for bringing the team together to make shared decisions that benefit the patient? That question cannot be answered by any single profession’s regulatory framework, no matter how well designed. It requires interprofessional governance: shared competency expectations, collaborative clinical guidelines and team-based accountability structures that cross professional boundaries while preserving each profession’s self-regulation.
A recent policy commentary examines this problem with precision – for paramedicine. Paramedics are increasingly working in primary care, urgent care and community settings far beyond the ambulance. But oversight is fragmented across medical directors, employers and regulators, with no one holding clear oversight. Advanced roles emerge through pilots and exemptions rather than deliberate system design. The result, as the authors argue, is structural fragility, not innovation. Their analysis is valuable. But it also illustrates a pattern that extends to every health professional being asked to work in team-based primary care.
This problem was anticipated two decades ago. Health Canada-funded research on interprofessional collaboration identified governance as a critical missing layer – the practice-level structures that connect what clinicians do on a team with the policies set by governments and regulators. William Lahey, a health law expert at Dalhousie University who contributed to that research, warned specifically that regulatory barriers were blocking collaborative practice – and that reform must strengthen professional self-regulation, not dismantle it. Twenty years later, we still underinvest in exactly this layer. We fund new roles, expand scopes and create education programs. But we don’t build what holds team-based care together: shared clinical protocols, quality assurance across professions and clear lines of team accountability.
Lahey went on to design the governance infrastructure his research said was needed. Nova Scotia’s Regulated Health Professions Network Act (2012) made all 22 self-regulating professions – including, since 2017, the College of Paramedics – members of a collaborative network enabling joint investigations, coordinated scope adjustments and shared registration appeals. Then in 2023, the province passed an umbrella Regulated Health Professions Act replacing 21 separate profession-specific statutes with a single framework. Crucially, Nova Scotia’s approach is bottom-up – regulators proposed and developed it – which means it strengthens self-regulation rather than undermining it. As Lahey himself later documented, this bottom-up approach may outlast top-down mandates precisely because it works with professional self-governance rather than against it.
Internationally, England offers a useful comparison. The United Kingdom’s National Health Service Centre for Advancing Practice has built explicitly multi-professional governance for advanced practice, applying the same competency framework to nursing, pharmacy, paramedics and allied health. Organizations self-assess against shared governance standards. The lesson is not that the U.K.’s system is perfect – a nationwide evaluation found persistent variation. It is that governance deliberately designed to be multi-professional creates a platform that can be improved. Governance that grows up profession by profession, in silos, produces fragmentation almost impossible to retrofit.
As Canada builds team-based primary care, the governance question must be asked at both provincial and federal levels: What does each profession need within its own regulatory framework to prepare members for team-based primary care? And what shared structures – competency expectations, clinical guidelines, quality assurance – need to exist across professions? Nova Scotia shows this is achievable within Canadian federalism. The U.K. shows it can work at scale.
We have the evidence and the precedents. We now need the will to build governance that matches the ambition of the teams we are creating.
